Australia: Failure to diagnose due to non-classical symptoms does not reflect poor care

Last Updated: 15 February 2016
Article by Hamish Broadbent

The Office of the Health Ombudsman (Queensland) ("OHO") recently published its report into the care of a patient by the Gold Coast Hospital and Health Service ("GCHHS"), finding that the service provided was adequate and did not require further action by the OHO being taken.

Complaint

In January 2014, a complainant initiated a complaint regarding the health services her late mother (the patient) received from Gold Coast and Robina Hospitals (of GCHHS) between 28 March 2013 and her death on 25 June 2013. The complainant's concerns were:

  1. There was a two to three month delay in diagnosing the patient's duodenal ulcer;
  2. Following diagnosis, no immediate treatment was taken to treat the ulcer; and
  3. The duration of the patient's illness on her death certificate is incorrect

Investigations

Submitted during the investigation were records from GCHHS, a GCHHS submission, a GCHHS Human Error and Patient Safety (HEAPS) report, and an update from the CGHHS regarding improvements relative to the HEAPS report. The HEAPS report identified training requirements for medical and nursing staff regarding Venous Thromboembolism ("VTE") prophylaxis education, and that the GCHHS introduced a new position within the clinical team to ensure improvement in this area.

An independent expert in gastroenterology and hepatology ("the expert clinician") was asked to provide a report identifying any areas of poor individual clinical performance or failure in overall clinical coordination by the GCHHS.

The Issues

The OHO identified the following issues, considering each in the context of the investigations, and making a determination following analysis of the evidence:

  1. On 28 March 2013 the patient presented with pain on her right lower chest. Was there a failure to appropriately diagnose the patient and was she improperly discharged? The expert clinician believed appropriate diagnosis, clinical assessments, investigations and treatments were undertaken based on the patient's presenting condition and symptoms. The clinical picture included a previous fall, history of osteoporosis and anaemia, no obvious GI bleeding, and bloods which were unremarkable for significant upper abdominal pathology. The clinician believed the hospital acted reasonably to rule out immediate life threatening problems and noted that a letter to the patient's GP requesting further assessment and investigation was appropriate.
  2. Between 8 May and 14 May 2013 the patient presented with pain on her right side. Was there a failure to diagnose and treat, and a lack of follow up of the patient's CT Scan results? The clinician noted that while there were some clues to an upper GI problem, the issue of adequate diagnosis depends on how the patient presented as she was reviewed each day. As a Category 2 patient, not critically ill when assessed, then performance of a GI endoscopy and ultrasound may have taken three months to undertake. Based on the CT report there were no clues that a perforation or collection was present at the time. The discharge was thus made when there was no identifiable cause for the symptoms, although the clinician suggested an oral contrast study may have helped.
  3. Between 17 June 2013 and 25 June 2013 the patient presented after losing consciousness at home and was in significant pain. Was there a delay in treatment and care from admission to time of death, and was there appropriate follow up following the patient's endoscopy? The expert clinician advised that the clinical picture was now more obviously pointing to an upper GI problem. Diagnostic procedure was quickly arranged but the resultant complication of a catastrophic GI bleed in a SC Heparin setting (a VTE prophylaxis), rather than a mechanical prophylaxis (in the form of a sequential calf compression devices and early mobilisation) was not the correct decision. Again an oral contrast study would have helped identify a perforation and would have then required surgical input. Nevertheless, the expert clinician considered that the medical team appropriately assessed the risk and benefits of the VTE prophylaxis, and thus the steps taken by the GCHHS were appropriate.
  4. The adequacy of notes of verbal communication between the patient, her family, and the treating practitioners. The HEAPS review considered definitive documentation making for VTE prophylaxis by the treating team would assist in improving practice. The expert clinician agreed.
  5. The overall treatment and management of the patient. The expert clinician was not able to identify that the patient's presentation was inappropriately diagnosed, assessed, investigated or treated at each presentation. The expert clinician was also unable to identify any health practitioner whose performance or conduct was below the standard reasonably expected. They also noted that while the root-cause analysis was very good, he did not believe that the medical management reflected poor care but simply a different diagnosis due to non-classical symptoms and investigations that proved negative and thus unhelpful in making the correct diagnosis.

Conclusion

Taking into consideration all the evidence, the OHO formed the view that the treatment and care provided by Robina and Gold Coast Hospitals was adequate. Given the complexity of the patient's multiple presentations and the fact that no individual health practitioner was identified as exhibiting unsatisfactory professional performance, no further action was taken by the OHO.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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